REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
June 27, 2023
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title
Revisions to Arrowhead Regional Medical Center Medical Staff Bylaws and Rules and Regulations
End
RECOMMENDATION(S)
Recommendation
1. Approve revisions to the Arrowhead Regional Medical Center Medical Staff Bylaws as detailed in Attachment A, effective June 27, 2023.
2. Approve revisions to the Arrowhead Regional Medical Center Staff Rules and Regulations as detailed in Attachment B, effective June 27, 2023.
(Presenter: William L. Gilbert, Director, 580-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of this item will not result in the use of Discretionary General Funding (Net County Cost). Revisions of Medical Staff Bylaws and Medical Staff Rules and Regulations are non-financial in nature.
BACKGROUND INFORMATION
The Medical Staff at Arrowhead Regional Medical Center (ARMC) is governed by the Board of Supervisors (Board) and operates under the Bylaws of the Medical Staff, Medical Staff Rules and Regulations (Rules), the Medical Staff Committee Manual, and Medical Staff Policies and Procedures.
The Medical Staff Bylaws (Bylaws) provide a framework for self-government for the Medical Staff organization at ARMC that permits the Medical Staff to discharge its responsibilities in matters involving the quality of medical care, to govern the orderly resolution of issues and the conduct of Medical Staff functions supportive of those purposes, and to account to the governing body for the effective performance of Medical Staff responsibilities. The Bylaws provide the professional and legal structure for Medical Staff operations, organized Medical Staff relations with the Board, and relations with applicants to and members of the Medical Staff.
The Rules provide the standards of professional practice for the Medical Staff and advanced practice professional staff at ARMC.
As the governing body of the ARMC Medical Staff, approval from the Board is required for all revisions and changes to the Bylaws and Rules, which are reviewed as necessary, but at least every two years.
The Medical Staff recommends the following revisions to the Bylaws, as proposed in Exhibit A, to be effective June 27, 2023:
• Section 5.9 is amended to give the Department Chair the ability to request the Credentials Committee or person(s) delegated by such committee to interview an applicant as part of the application process and to require that all Committee on Interdisciplinary Practice be reviewed by the Credentials Committee prior to being forwarded to the Medical Executive Committee for final action (page 25).
• Section 6.2(F)(2) is amended to indicate that practitioners that already hold clinical privileges in a department may perform those privileges through a telemedicine link where certain requirements are met (page 31).
• Section 7.9(c) is amended to indicate that practitioners must complete medical records within the timeframe required under the Rules and the Medical Staff Policy on Medical Record Delinquency and Suspension and outlines when a suspension of privileges may be imposed for failure to timely complete medical records (page 51).
The Medical Staff recommends the following revisions to the Rules, as proposed in Exhibit B, to be effective June 27, 2023:
• Minor editorial modifications throughout the Rules.
• Expands the definition of an urgent, emergent, and elective admission in Article 1.
• Article 4 is revised to clarify the contents required of a medical record, which includes, among other things, history and physical examinations, reports of surgical and other major invasive procedures, discharge summary, and outpatient clinic records. The revisions also clarify what must be included in the documentation for history and physical examinations, progress notes, reports of surgical and other major invasive procedures, consultations, authentication of chart entries, discharge summaries, and outpatient clinic records.
• Article 12 is revised to clarify that restraints and/or seclusions must be ordered pursuant to the applicable administrative policy.
• House Staff and Medical Student responsibilities moved to last section/page.
ARMC recommends approval of these revisions. This approval process is in accordance with the Bylaws; Centers for Medicare and Medicaid Services; California Code of Regulations Title 22, and the standards of The Joint Commission.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by the Medical Executive Committee (Kambiz Raoufi, MD,
Chairman, 580-6267) on March 23 2023; County Counsel (Charles Phan, Deputy County Counsel, 387-5455) on May 22, 2023; ARMC Finance (Chen Wu, Budget and Finance Officer, 580-3165) on June 2, 2023; Finance (Jenny Yang, Administrative Analyst, 387-4884) on June 6, 2023; and County Finance and Administration (Valarie Clay, Deputy Executive Officer, 387-5423) on June 7, 2023.